Ep 261: When Your First FET doesn't conceive: Tips to Try

Join Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Abby Eblen from Nashville Fertility Center, and Dr. Susan Hudson from Texas Fertility Center as we delve into listener questions about the complexities of failed IVF cycles, offering insights and hope for young couples facing infertility challenges. We explore factors contributing to poor implantation after frozen embryo transfers and discuss advanced diagnostic tools like the ReceptivaDx, ALICE, and EMMA assays, which help identify underlying issues such as endometriosis and uterine microbiome imbalances. We also examine the sperm QT test to determine the necessity of ICSI in subsequent cycles. Our conversation covers the pros and cons of modified natural cycles versus programmed cycles, the role of laparoscopy in evaluating endometriosis, and strategies for managing PCOS, particularly when egg maturity is a concern. We provide guidance on treatment adjustments after one or multiple failed cycles, discuss the appropriateness of using Lovenox, and consider when hysteroscopy is indicated for detecting polyps. Join us for a comprehensive discussion aimed at empowering couples on their fertility journey. Have questions about infertility?  Visit FertilityDocsUncensored.com to ask our docs. Selected questions will be answered anonymously in future episodes.

Transcript

Susan Hudson (00:01)

You're listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

Susan Hudson MD (00:22)

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Visit www.levy.health/fdu and use code FDU10 at checkout for 10 % off. Levy Health, decoding your fertility.

Abby Eblen MD (01:04)

Hi everyone, we're back with another episode of Fertility Docs Uncensored. I'm one of your hosts, Dr. Abby Eblen from Nashville Fertility, and today I'm joined by my lovely and talented co-host, Dr. Susan Hudson from Texas Fertility Center.

Susan Hudson MD (01:16)

Hello everyone.

Abby Eblen MD (01:18)

and Dr. Carrie Bedient from Fertility Center of Las Vegas. How are you guys doing? Doing good. I think I'm at the point where I'm looking forward to the spring and warm weather and I'm sort of daydreaming. I don't know if you've ever gotten something pop up on your computer and you look and you're like, God, I wish I could just hop into my computer and be in that spot. So my question for you guys today is, if you had to choose a really cool place that you've never been, Carrie, where would you go?

Carrie Bedient  MD (01:22)

Speaking of the internet things that pop up, I get the Maldives with those beautiful overwater bungalows and the super clear water. And that is my pipe dream one day. I would also settle for Tahiti or some other place. And by settle, mean, eagerly go and hop on a plane within 30 seconds or less. But that's where I would love to go now I still have yet to figure out how to make this happen because it's like 24 hours of travel to get there and you need the time off. And as doctors who gets time off? That is my dream vacation one day. What about you guys?

Susan Hudson MD (02:25)

I would really like to go to New Zealand. I just want to go to Hobbiton and...

Carrie Bedient  MD (02:29)

I was about to ask, you're a big Lord of the Rings fan and that's...

Abby Eblen MD (02:33)

I didn't even catch that. Okay, so Lord of the Rings.

Susan Hudson MD (02:36)

Yes, yes. I just think it would be a beautiful place to visit and I've never met anyone who's been there who was like, it wasn't worth the trip. But again, it's that crazy, crazy long travel and so you have to have enough time to get there, recover, and then enjoy whatever you're going to do. So that just adds extra time onto it.

Carrie Bedient  MD (02:56)

I had an acquaintance who went there who got in essentially giant hamster balls and rolled down these big, gorgeous hills. And it was stabilized in some way. So it wasn't like they were going head over heels, head over heels. Like there was a ball inside of a ball. But if you go there, can you do that and send me videos, please? Thanks.

Susan Hudson MD (03:14)

I will, I can't guarantee you I'm gonna get into a giant hamster ball, but if I can con some of my family into do it, I'll take some videos.

Carrie Bedient  MD (03:22)

Excellent. What about you, Abby?

Abby Eblen MD (03:24)

Well, I would like to go to Japan just because it's exotic, kind like you guys somewhere far, far away that's really exotic and to explore a different culture and understand history of Japan and their people. And I just think it'd be really cool to go there.

Carrie Bedient  MD (03:36)

Are you going to plan it during the cherry blossoms blooming?

Abby Eblen MD (03:39)

And I was just had visions of cherry blossoms. was thinking, yeah, that would be really cool to go there if you could time it correctly.

Carrie Bedient  MD (03:45)

Feel like the artist in you would come back with gorgeous photos or gorgeous paintings and photos of that.

Abby Eblen MD (03:48)

That would be really, yeah, definitely. A very inspirational trip, think, for sure. So, very cool.

Carrie Bedient  MD (03:54)

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Receptiva Diagnostics because the journey is worth it.

Abby Eblen MD (04:22)

So today, we're gonna talk about things that we can potentially do for failed cycles, and we're gonna answer listener questions regarding failed cycles. So, Susan, do you have a question for us?

Susan Hudson MD (04:32)

All right, here's our first one. It has to do with recurrent implantation failure. My third FET failed to implant and I'm devastated. I was very lucky that my retrieval resulted in 10 embryos frozen, but opted out of PGT-A. Context, almost 34, AMH 1.77 PCOS, BMI greater than 40, one child via IUI. No history of losses, seven embryos left with good grading. Where do I go from here?

Abby Eblen MD (05:00)

What do you think, Carrie?

Carrie Bedient  MD (05:02)

So PGT-A is one thing to think about. And I always think getting the, getting a handle on where you are emotionally is helpful in this because there are some people who don't want to take the risk of thawing an embryo, biopsying and going through that. There are other people who would much rather take that risk so that they know which embryos are good and which ones are not so that they can then go forward and get a better idea of which ones to actually transfer. So I think that's probably one big question you want to consider going forward.

Susan Hudson MD (05:34)

Would also say at this point, I would recommend a hysteroscopy. Probably about 10 years ago, there was a good study performed that said if somebody has had normal saline ultrasounds or HSGs and they've had two failed embryo transfers, that at that point, about 30 % of people have some sort of intrauterine pathology that's only diagnosable and obviously treatable via hysteroscopy.

That would be an important concept at this point as well. My other comment, and I know this is always a very delicate subject, but you have a BMI over 40. And even though you've had a successful pregnancy and we all know people who have higher BMIs who have been successful, it is an independent risk factor for failed implantation as well as future miscarriages and just overall pregnancy complications, including preeclampsia or high blood pressure issues in pregnancy, diabetes in pregnancy, increased risk of C-section, and complications of all those things.

Abby Eblen MD (06:39)

Yeah, and the other thing that I would add in that I talked to couples about when they've had a couple of failed FETs is also to think about doing uterine testing. And there's not a lot of great data, unfortunately, which unfortunately that our field, we have a lot of things we can do, but not a lot of great data to support what we do. The Receptiva assay is one that looks for an inflammatory marker called BCL-6. And so if that inflammatory marker is present, that's bad. That means it lowers your chances of implantation. Doesn't make it zero, but it lowers it.

And so it's just basically we find that by doing a simple biopsy of your endometrium, has to be timed with your menstrual cycle. I do that pretty commonly and people are at least to offer that to couples after a couple of failed transfers.

And I would just throw in my two cents about what Carrie said too about genetic testing. There's some data to suggest that it does impair the ability of the embryo to thaw a second time after it's been thawed, biopsied, and refrozen. But I will say before that study came out that suggested that, I had several patients that came to me that we rethawed their embryos, we tested them, and for all the, really, I mean it was maybe five or six people.

But for all those patients, it turned out great. Their embryos did fine and I think most if not all of them got pregnant. So my bet is I don't think it causes significant damage because you're talking about an embryo that has 140 cells. Now, if you're talking about an embryo, when we used to freeze embryos on day three, those embryos only had six or eight cells. And if you thought that embryo out and two cells didn't survive, you're talking about a fourth to a third of the whole embryo that didn't survive.

Embryos now are fairly hardy just because there's more cells there and so with so many embryos you might even consider thawing even a certain percentage of them maybe five or five of them or something if you're concerned about thawing all of them and testing them genetically because even based on your age and if you had ten embryos statistically probably somewhere around five are genetically abnormal and you may have just been really unlucky and they picked three of the ones that were genetically abnormal and you didn't know it.

Susan Hudson MD (08:35)

And we've all seen people who've had multiple embryos, and half or more may be abnormal. And it literally is a flip of the coin if we're picking the right one because understand that even when embryos are graded, that has absolutely no correlation to chromosomal normality. there's no appearance at this point in time that we can confidently say, hey, we need to be able to do this.

Abby Eblen MD (08:40)

Yeah.

Carrie Bedient  MD (09:01)

It's not just the beauty competition, it's also the talent competition. So those chromosomes make a big difference. And keep in mind, it's not just the chromosomal testing with the PGT-A itself. It's also the function of all those little organelles, which are the tiny little pieces, parts and pieces of machinery that go along with it. And those may or may not be functioning well. And unfortunately, we don't always have a really great way of assessing that.

Abby Eblen MD (09:05)

Hahaha.

Carrie Bedient  MD (09:27)

And so that can impact the ability of an embryo to implant, grow and keep on going.

Abby Eblen MD (09:32)

Do we have another question?

Susan Hudson MD (09:33)

We do, we do. Hi docs, I'm 34, turning 35 soon. Diagnosed with unexplained infertility. Got pregnant once with Clomid, but miscarried at seven weeks. Husband's sperm is off the charts normal. AMH 0.9, HSG normal. I've had some polyps removed twice via hysteroscopy. We've done one round of IVF with 20 eggs retrieved, 12 fertilized, six blasts, four PGT normal. That's good.

Abby Eblen MD (09:59)

That's good. That's great.

Susan Hudson MD (10:01)

All right, we failed two modified natural transfers of euploids graded AA and AB. Doc recommends doing a laparoscopy for endo. Not a candidate for Lupron due to horrible side effects with my mood and I did not tolerate oral estrace for FET because I developed a lot of pain and cystic structures in my lining. I am wondering if we should seek help for laparoscopy or what you think are the next steps. We are at a loss.

Abby Eblen MD (10:28)

I think laparoscopy would be a reasonable option. We don't do it as much anymore, but I think there's certain situations where it can be really beneficial. I've seen a couple of patients that, and these are anecdotal, this is not a randomized perspective study or anything, but that have had pretty severe endometriosis, and we suspected it because we saw cyst of endometriosis on the ovary, and it doesn't sound like that's your situation, but even in those patients, did a couple of months of Lupron, then transferred them, and two of those patients didn't get pregnant.

So then they went back and had laparoscopy and it may have been anecdotal, but both got pregnant after that. So I really do think there's some benefit maybe to going in and ablating endometriosis. And of course, you don't really know if you have endometriosis, number one, so it's a little bit of a gamble there. But I would say 10 years ago, we would routinely laparoscope patients even after three to six months of treatment if they weren't pregnant. So I don't think it would be out of the realm to consider that as an option. The other thing I would say if you were my patient is I probably would

consider trying maybe a program cycle rather than the modified natural cycle. Some patients just do better with a different type of cycle and I feel better sometimes if I can control things a little bit better by giving both estrogen and progesterone. And so that's something that I would also consider as well.

Susan Hudson MD (11:42)

So a couple of comments. One, what would you all think about instead of going straight to laparoscopy, doing a Receptiva test to see if you actually have BCL-6 in the endometrium, and if it's positive because she doesn't look like she's a candidate for Lupron, then doing the laparoscopy, what would you think about that thought process?

Abby Eblen MD (12:04)

Yeah, I mean, think that would be certainly valid. And I guess that's if you think that's the only impact that endometriosis has. I mean, I guess we don't really know for sure if it has other impacts, but yeah, I mean, I think that would be a certain, certainly a less invasive way to consider doing that and to make a decision based on that.

Carrie Bedient  MD (12:20)

One of the things that the Receptiva folks are looking into is for patients who can't, won't, don't tolerate Lupron, doing Letrozole in advance. And so the success rates seem to show that it's not quite as good as Lupron, but if you can't take the Lupron, then doing the two months of Letrozole, and I want to say it's a dose of five milligrams. I can go back and look for that one, but four, five, yeah.

Susan Hudson MD (12:41)

It was five milligrams.

Yeah.

Carrie Bedient  MD (12:44)

And so give five milligrams every day and see how that goes because if you've done well on modified natural cycles usually when people say modified natural that means that they're taking letrozole with it. The other thing is depending on the type of modified natural cycle that you are doing, there's some people who will do progesterone and oil with those and there's some people who won't and they will just completely go by the spontaneous ovulation that you have in your tracking with that. One way to consider modifying that if you

Particularly if you have a negative Receptiva or no signs of endometriosis, one sign of modifying that would be to do the progesterone and oil and an HCG trigger. Now, you may be already doing those. For some people, that's a default. When they say modified natural cycle, for others, it's not. So it just kind of depends on what modified natural means to you and your doctor.

Susan Hudson MD (13:31)

All right, let's get to our next one. Hi Docs, 32 years old, trying to conceive for three years with no pregnancies, diagnosed with PCOS, husband has normal sperm. We just had our first IVF cycle with disappointing results. Only one freezeable day six blastocyst. AFC 31, AMH 2.94, antagonist protocol with Rekovelle and 75 IUs of Menopur added on day three.

Also taking dexamethasone, triggered on day nine with Ovidrel, 15 eggs retrieved, all were mature but only seven fertilized. On day five, no blasts, and day six, morula phase. Clinic transferred my best on day five, morula. Ultimately, one made it to blast on day six. Also, despite my request, my clinic would not do ICSI because they said there was no issue with the sperm quality. Wondering if you lovely ladies have any suggestions or recommendations for our next IVF.

I think we're all thinking the same thing.

Carrie Bedient  MD (14:28)

I think we all probably have like four or five sets of thoughts.

Abby Eblen MD (14:32)

There's a lot of layers there. was trying to like take it all down.

Carrie Bedient  MD (14:36)

So one thing to consider is it sounds like this was a fresh transfer. And unsurprisingly to Susan and Abby, that's the first thing that I'm going to suggest an alternative to, just because fresh cycles are not terribly ideal. Fresh cycle is a compromise of both getting the embryos and transferring the embryos. And compromise is wonderful in friendships, relationships, marriage.

It sucks in the IVF lab and in the context of IVF because you want the maximum and the best for everything. And so what that means is that you push as hard as you can with a fresh cycle to get those embryos to do PGT testing if that's in the cards and then to come off of all those meds, return to your normal baseline and then do a much gentler stimulation for the endometrium that's really designed to optimize that. And so when you try and combine those two and mash them together, it's not that it's not gonna work. Years and years and years of experience shows that fresh transfers do work. It's just when you're comparing them to frozen transfers, they don't work as often. And now in a type A overachieving, striving, not just society, but field in general, we wanna maximize everything we can. That is one relatively simple way to do that. It also gives you a chance to recover between cycles, which is nice when you feel like you've been battered by the hormones and you want to simmer down, take a minute to breathe, and then move forward for a transfer.

Abby Eblen MD (16:01)

What are your thoughts, Susan?

Susan Hudson MD (16:03)

Well, my thoughts are just because you have a normal semen analysis does not necessarily mean the sperm is completely normal. So one test I highly, highly recommend would be something called a Sperm QT test. So Sperm QT looks at genes that determine how well the sperm can bind to penetrate and actually fertilize the egg. And these genes can become what we call dysregulated or abnormally turned on or off.

As you go through life through different life experiences, exposures, all kinds of things. And so if you have an abnormal Sperm QT, which is not correlated with how well a semen analysis looks, essentially your sperm get to the egg and they don't know how to ring the doorbell to get in. So you could have millions and millions of sperm, but they're just sitting there being like, we're sitting here waiting for somebody to open the door and the egg doesn't act that way.

Okay, which is what essentially would be needed to get in through standard insemination. And if you did have abnormal Sperm QT using ICSI where we do inject the best looking sperm into each egg gets the sperm into the egg. And once the sperm get in the egg, they still have all the mechanisms they need to complete the fertilization process and go on to develop additional embryos. Something that's a little more on kind of some people believe on it, some people don't is DNA fragmentation within the sperm. DNA is our genetic code. It's what's held within the sperm. We know again, sometimes DNA can become more broken or fragmented. And if that's present, there are a couple of different options of how sperm can be processed to help improve outcomes, whether it is through having a testicular biopsy, so getting some sperm that are a little upstream with lesser degrees of fragmentation or potentially using a device called a Zymot device that sorts the sperm, the sperm that come out the other end, have lesser degrees of fragmentation, thereby giving better chances of pregnancy and less risk of miscarriage.

Abby Eblen MD (18:05)

Yeah, some practices do that, so we don't routinely do Zymot unless somebody really wants to do it, but certainly that's a good option. The other thing I thought about was if you said you had an AFC count of 31, you have PCOS, you're 32 years old, and you only got 12 eggs, and that's not a bad number, but for somebody with your age and your AFC count, I would have expected to get more eggs. Sometimes we tend to see if you have polycystic ovary syndrome that your eggs just don't grow quite as quickly or are mature quite as well. You were on Menopur, and that's one of the things that I would add in if you've not been on Menopur, but sometimes we have to grow, and this is one of those things where you may have already talked to your doctor about this, but most likely they're gonna change your protocol a little bit if you were to go back through IVF again. And so I suspect that they probably would consider putting you, maybe not on more medicine, but pushing you a little bit longer, because sometimes the eggs that we get from PCOS patients are just even with the follicle, even when the fluid fills sac around the egg, it says that the egg should be mature. Sometimes PCOS eggs are just not mature. And so it may be that your doctor may wanna push you an extra day if they can to try and get a bigger bunch of eggs to mature. And I think most of us now tend to push eggs, thanks to one of the studies done in Carrie's practice, tend to push patients further if you're doing a frozen transfer instead of a fresh transfer, Carrie just mentioned. And so by doing that, you can really optimize the growth of the eggs and get as many or as many eggs as possible mature and you don't compromise the endometrium because those are gonna be two separate steps that you're gonna do. So that's the one thing I would consider if you were my patient to see if I could push you a little bit longer to get more maturity out of the eggs.

Susan Hudson MD (19:42)

I think her doctors were probably trying to do a pretty gentle stimulation because they were trying for a fresh embryo transfer and avoiding that Lupron trigger because if you are somebody who recruits a ton of eggs, then you're at a higher risk of that ovarian hyperstimulation syndrome or OHSS. And using a Lupron trigger can help minimize those risks, but it also relatively eliminates the chances of a fresh embryo transfer.

Abby Eblen MD (19:48)

Yeah.

Susan Hudson MD (20:08)

All right, we ready for another one? Okay. Hi, I love the podcast. Staying informed and doing research helps me keep calm during high anxiety situations like fertility treatment. So the information y'all provide has been so helpful. I am 25, husband is 28, I have PCOS. No luck with letrozole to induce ovulation, ended up doing IVF. Great stem with 45 eggs, 31 mature, 21 blasts, 18 normal.

Abby Eblen MD (20:36)

Wow.

Susan Hudson MD (20:38)

That is an overachiever. That's awesome. Did our first transfer a few months ago, which ended in miscarriage at six weeks, doing another saline ultrasound and an endometrial biopsy prior to our next FET. We'll also be adding more meds in the next FET, additional blood thinner, antibiotic, steroid. What are your thoughts on the additional meds? How likely will this approve outcomes? How to manage expectations going into the next FET.

Feeling much more anxious for this transfer. Thank you.

Carrie Bedient  MD (21:09)

I'm curious what the endometrial biopsy is looking for. I'm curious to see are they doing a Receptiva? Are they doing an EMMA, an ALICE, an ERA, like any of these other things? Because it used to be that we would do endometrial biopsies all the time to get an idea of what phase the uterus was in. And that has since not really proven to be quite as helpful.

Carrie Bedient  MD (21:33)

And so I'm curious as to what they're looking for. Now the saline ultrasound, that totally makes sense. Going ahead and doing a hysteroscopy, that totally makes sense to me for evaluation. But I'm really curious as to what they're looking for with the endometrial biopsy.

Abby Eblen MD (21:45)

Well, I will say there are still doctors around that do endometrial biopsies just to look for infection. So just doing endometrial biopsy just for infection. So that could be it too. But certainly I don't do that.

Susan Hudson MD (21:55)

So essentially what we're saying is more information of what types of biopsies are happening. A biopsy is likely to provide some piece of information, but there's lots of different things that can be achieved from that.

Carrie Bedient  MD (22:08)

And knowing what you can get from a biopsy if you're looking for infection, looking at the specific infection cells, you can somewhat pick up on a biopsy, but it's not necessarily guaranteed just because a biopsy is a random sampling. And when you pull that random sampling, you might get it or you might not. And that can really affect the value of the results. So looking at it in addition to doing the biopsy is really helpful.

And if you guys are hearing all sorts of dog sounds in the background, I apologize. My puppy dog has decided that in my lap is the only acceptable place for her be during their recording. So if you hear barking and shaking, it's not me, it's the dog.

Abby Eblen MD (22:37)

Aw. Cute!

Very good. Well, so in terms of the Lovenox, I think it's a little early to jump the gun on Lovenox. There's nothing in the information that you gave us that would make me think that you would benefit significantly from Lovenox. There's data to show that if you have recurrent pregnancy loss and you test positive for either lupus anticoagulant, anticarolopin antibodies, that there may be some benefit to that.

Susan Hudson MD (22:49)

Good stuff. Good stuff.

Abby Eblen MD (23:15)

Lovenox, I used to be a little bit more likely to prescribe it, but it's a pretty potent medicine. If you were on it and you were in a car accident or if you fell in your kitchen while you were up on your cabinet getting something, it could cause significant bleeding in bad places like your head or your lungs or something. I don't think after one failed transfer I would do that. I would recommend doing that. As far as the steroid, that's probably not going to hurt anything. It could help some people really swear by that, other people don't. You've had the one loss, but even an unexplained loss sometimes can be, there's a lot of other things other than just the genetics that can cause a loss. And so I would probably not jump to Lovenox at this point.

Susan Hudson MD (23:53)

I agree with Abby. I'm very evidence-based when it comes to Lovenox because bad things can happen and this isn't like just popping an aspirin tablet. So if you want to take some aspirin as a blood thinner, I think that's fine.

But unless you have evidence of antiphospholipid antibody syndrome, I would steer away from that. And probably by the time you get discharged to your OB-GYN, your OB-GYN is probably going to take you off of it. They're not going to be real happy about that. I I use steroids in my patients who've had failed cycles or people who have different autoimmune conditions and different things like that. So I think those things are reasonable.

But I do think that being cautious on blood thinners is something good to do.

Abby Eblen MD (24:46)

All right, we got one more.

Susan Hudson MD (24:48)

Yes. Okay. Hi. Thank you for your podcast. I've gained a lot of information. I'm 34, currently have a 20 month old. We conceived naturally after four months of trying. We wanted to try again, but got blood work done and my AMH dropped from 2.75 to 0.92.

We were referred to a fertility specialist and did two rounds of IUI that both failed and are moving to IVF. We did our first transfer which failed and ended up having a hysteroscopy after to remove a polyp from the uterus. Our second transfer was successful but resulted in miscarriage at five and a half weeks. What next steps including tests would you suggest?

Carrie Bedient  MD (25:27)

So first question in all of this is any PGT testing, which is not required when you're really at any age, but there's value to it because you will ultimately get to the same result, but the path that you travel to get there is very different. And so that's one thing to consider. I'm curious as to what else they saw when they went into the hysteroscopy. Was there signs of inflammation there?

Is that something where it may be worthwhile to take an extra couple of doses of antibiotics to cut down inflammation? Now, if they didn't see any redness, then no, that's not particularly useful. If they did, that's something that's worth considering. The drop in the AMH component of this makes me wonder about egg quality, but it also makes me wonder about the accuracy of the AMH level because depending on when that was drawn,

Abby Eblen MD (26:18)

That's a big one.

Carrie Bedient  MD (26:18)

If you happen to be at a timeframe when you were really suppressed, like let's say you were breastfeeding and not ovulating, you had been on birth control for a while, in between having your baby and being ready to conceive the next one. Those can have an impact as well. So it might be worthwhile to recheck that to see if that's really as low as it is, because if it is, maybe give that a little bit more thought. If it's not, then you can kind of cross that off of your list of something to be super worried about.

Abby Eblen MD (26:46)

Yeah, one of those two seemed like a spurious value and it's just hard to know which one. Did she say when she went through IVF how many eggs she got or embryos? She's had two transfers, so she at least had two and based on her age, I mean, two to four is kind of what I usually say. So it suggests that maybe the second AMH like Carrie said was really spurious and not real. So yeah, I would sort of echo what Carrie said too. I think hysteroscopy.

Susan Hudson MD (26:54)

She did not.

Abby Eblen MD (27:11)

If there was infection there, we could treat it. Certainly you might want to consider a Receptiva assay specifically if you only have, usually if you only have one embryo left, that would definitely be the time I would talk to you about it. But after, having no pregnancy and then, or actually a miscarriage the first time around.

Susan Hudson MD (27:27)

So she had had a, she has a 20 month old son and then did two rounds of IUI and then went on to IVF, had a failed embryo transfer and then a miscarriage.

Abby Eblen MD (27:39)

Okay, yeah, I mean I might consider doing a Receptiva assay just because I do think it gives value and at least if it's negative you'll know it's negative and you won't worry about inflammation in your endometrium.

Susan Hudson MD (27:50)

And Receptiva is something that can, looking at BCL-6, it can influence both getting pregnant and staying pregnant. So it actually really addresses both issues with your kind of failed transfers.

Carrie Bedient  MD (28:03)

One question related to that one for you guys. At what point do you pull the trigger on recurrent pregnancy loss labs like the anti-cardiolipin, the antibodies, and those types of things? I typically do it, I start to think about it for sure after two failed cycle, two failed transfers of euploid embryos, especially in a younger woman. But what's, what are your thresholds? What are your cutoffs if you've got tested embryos versus not tested embryos, age of the patient, all those things?

Abby Eblen MD (28:19)

Yeah, for sure.

Susan Hudson MD (28:29)

My threshold is really low. Most of my patients do PGT, so if they've had a failed embryo transfer with a PGT-tested embryo, whether it's failure at implantation or a miscarriage, I offer recurrent pregnancy loss evaluation at that point. If they're untested, I would probably do it after two, just because I know that at least I had a 50-50 chance that the problem was the embryo itself.

But it's simple blood tests and so I'm pretty quick to offer.

Abby Eblen MD (29:03)

Yeah, I usually, I don't do recurrent pregnancy loss after just one failed transfer because there's so many things that could go wrong that don't have anything to do with that. I think certainly if somebody wanted me to do it, I would, but not everybody has coverage for all those tests and they can be expensive if you're paying out of pocket. But I think if you only had one embryo left, for example, I think I'd try to pull out the kitchen sink if I could. So certainly, consider that if there's only one embryo left.

What about you, Carrie?

Carrie Bedient  MD (29:27)

I tend to pull the trigger pretty quickly. If it crosses my mind, I generally offer it. It's with the caveat it's not always covered by insurance. And so with insurance being somewhat finicky about whether or not they cover it, these tests are expensive. And how specifically expensive they are for you varies based on your coverage and which lab you're going to and all of those things.

Abby Eblen MD (29:50)

Which plan you have?

Carrie Bedient  MD (29:52)

What plan you have and it's not just the company, but it's the plan and what your employer springs for or not. And so that's something that it's very difficult for my office to answer, will it be covered or not? And that's true of pretty much all labs because those are going out to an outside facility. But that's something that I would consider. And I would also factor the financial into your calculations, call the lab company and just see what they may charge if it does end up coming out of pocket for you.

Susan Hudson MD (30:24)

But even if you had to, the most expensive of the tests that we're going to do are usually going to be the antiphospholipid antibody panel. If you did not do PGT, then potentially chromosome test on each of the partners. But the cost of those things are probably less than a frozen embryo transfer. Definitely less than a new IVF simulation.

And so you need to measure where your heart and your brain are coming together on whether you want to do that additional testing. I'll sit down with patients and I'll be like, okay, these are the things I feel strongly about. These are the things that I think are available and you can do now. If we're not successful this next time, I'm going to be a lot more pushy on our next cycle.

Carrie Bedient  MD (31:05)

Absolutely.

Abby Eblen MD (31:06)

All right, well, to our audience, thanks for listening. Tune in next week for more. Also be sure to subscribe and leave us reviewing iTunes. We'd really love to hear from you.

Susan Hudson MD (31:14)

Visit FertilityDocsUncensored.com to submit questions and sign up for our email list.

Carrie Bedient  MD (31:20)

And be sure to subscribe, let us know, help us get as much reliable information out as we can. And as always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we will talk to you soon. Bye.

Carrie Bedient  MD (31:36)

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